Menopause Myth #18: The Menopause Isn’t Linear: Why You Can Feel Worse Before You Feel Better

“I thought HRT was supposed to make me feel better, but I feel worse.”

A 48-year-old woman sits in front of me, frustrated and close to tears. She started HRT (transdermal oestrogen patch and micronized progesterone) six weeks ago for severe perimenopausal symptoms: debilitating hot flushes, night sweats disrupting sleep, brain fog, anxiety, and profound fatigue.

“The first week was amazing,” she tells me. “My hot flushes stopped almost immediately. I felt like I could think clearly for the first time in months. I had energy. I thought, ‘This is it — I’m fixed.'”

“But then in week two, everything crashed. The hot flushes came back. I felt anxious and on edge. I was bloated and my breasts were so sore I couldn’t wear a bra. I felt worse than before I started HRT.”

“By week three, some of the initial improvements came back, but I’m still having ups and downs. Good days and terrible days. I can’t predict how I’ll feel day to day.”

She looks at me with desperation. “Is the HRT not working? Should I increase the dose? Try something different? Or just stop altogether?”

This is such a common experience — and one that catches many women (and their healthcare providers) off guard.

The expectation: Start HRT → symptoms immediately and steadily improve → feel better week by week in a predictable upward trajectory.

The reality: Start HRT → initial improvement OR initial worsening → fluctuations → gradual overall improvement with ups and downs → eventually stabilize (usually 3-6 months).

Recovery from perimenopause is NOT linear.

Let me explain what’s actually happening and why this matters.

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The Myth: Treatment = Immediate, Steady Improvement

The pervasive expectation: When you start treatment for any condition, you should feel progressively better day by day, week by week. If symptoms worsen or fluctuate, treatment isn’t working.

Why we expect this:

• This is how many medications work (antibiotics for infection, painkillers for headache — you take them, symptoms improve)
• Linear improvement feels logical and predictable
• We’re conditioned to expect fast results

The reality for menopause treatment:

• HRT affects complex, interconnected hormonal systems that have been in chaos
• Your body needs time to adjust to stable hormone levels after months/years of wild fluctuations
• Symptoms often worsen temporarily before improving (adjustment period)
• Improvement is gradual, often with fluctuations
• Full effect takes 3-6 months (not days or weeks)
• Even after stabilizing, you may have “good weeks” and “challenging weeks”

This non-linear pattern is NORMAL — not a sign of treatment failure.

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Why Symptoms Fluctuate (Especially Initially)

Several factors explain why recovery from perimenopause symptoms isn’t a smooth upward line:

1. Your Body Is Adjusting to New Hormone Levels

During perimenopause, your hormones have been:

• Fluctuating wildly (10-fold changes within single cycle)
• Unpredictable
• Generally declining but with random surges
• Your body adapted (as best it could) to this chaos

When you start HRT:

• You suddenly introduce stable, consistent oestrogen levels
• Your body’s regulatory systems (which have been trying to compensate for fluctuating hormones) now need to recalibrate
• This adjustment period can cause temporary symptom worsening or new symptoms

Think of it like this: Your thermostat has been broken, randomly making your house too hot or too cold. You’ve adapted by constantly adjusting layers of clothing, opening/closing windows, using fans. Now the thermostat is fixed and maintaining steady temperature — but your body is still in “compensation mode,” over-responding until it learns the environment is now stable.

2. Different Symptoms Improve at Different Rates

Not all symptoms respond to HRT on the same timeline:

Fast responders (days to 2 weeks):

• Hot flushes often improve quickly (within days to 2 weeks)
• Night sweats often improve quickly
• Some women notice initial energy improvement

Moderate responders (4-12 weeks):

• Sleep quality (if disrupted by night sweats or hormonal fluctuations)
• Mood symptoms (anxiety, low mood, irritability)
• Joint pain, muscle aches
• Some cognitive symptoms (brain fog, concentration)

Slow responders (3-6 months):

• Full cognitive function restoration
• Energy levels fully normalize
• Libido (if affected by hormones)
• Body composition changes
• Skin, hair quality improvements
• Vaginal/urinary symptoms (even with topical oestrogen)

What this means: You might notice hot flushes improve immediately (week 1-2) while energy, mood, and cognitive function take months to fully improve. This creates a sense of “partial improvement” that can be frustrating.

3. You’re Still Perimenopausal (If Still Having Periods)

If you’re in perimenopause (still having periods, even irregularly):

• Your ovaries are still functioning — erratically, but still producing hormones
• Some months they produce more oestrogen, some months less
• HRT provides baseline stable hormones, but your ovaries are still adding unpredictable amounts
• Result: Total hormone levels fluctuate (HRT baseline + variable ovarian production)

This is why perimenopause on HRT can still have fluctuations:

• Some weeks you might effectively have “too much” oestrogen (HRT + unexpected ovarian surge)
• Other weeks just the HRT amount (ovaries quiet)
• Symptoms fluctuate accordingly

This improves once you’re fully postmenopausal (ovaries no longer producing hormones, HRT is your only source — more stable).

4. Side Effects vs. Adjustment Effects

When you start HRT, you may experience:

True side effects:

• Breast tenderness (especially first few weeks)
• Bloating, fluid retention
• Nausea (more common with oral oestrogen)
• Headaches
• Mood changes

vs. Adjustment effects:

• Temporary return of symptoms during adjustment period
• Fluctuations as body recalibrates
• New sensations as tissues respond to oestrogen (e.g., increased vaginal discharge as tissues rehydrate)

Distinguishing between these is challenging — but matters for deciding whether to persist or adjust treatment.

5. Progesterone Adjustment

If you have a uterus, you need progesterone alongside oestrogen.

Progesterone can cause its own adjustment effects:

• Mood changes (particularly first few weeks)
• Bloating, breast tenderness
• Fatigue
• Some women describe feeling “flat” or emotionally blunted
• Headaches

Different progesterone types have different side effect profiles:

• Synthetic progestogens (norethisterone, medroxyprogesterone) often cause more side effects
• Micronized progesterone (Utrogestan) typically better tolerated
• Mirena coil (levonorgestrel) provides local progesterone with minimal systemic effects

If progesterone side effects are significant, discuss switching type with prescriber.

6. Expectations vs. Reality

Psychological factors affect perception:

Initial placebo effect:

• First few days/weeks on HRT, many women feel dramatically better
• Some of this is real (hot flushes do improve quickly)
• Some may be placebo effect, relief at finally having treatment, hope
• When adjustment phase hits (week 2-4), feels like “crashing” because contrast with initial high

Hypervigilance to symptoms:

• Once you start treatment, you’re monitoring symptoms closely
• May notice things you weren’t paying attention to before
• “Is this better? Worse? Different?”
• Heightened awareness can make fluctuations feel more dramatic

Impatience:

• Understandable desire for immediate relief after months/years of suffering
• Each “bad day” feels like failure or proof treatment isn’t working
• Difficult to maintain patience through 3-6 month adjustment period

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The Typical Timeline: What to Expect

Understanding the typical timeline helps set realistic expectations:

Week 1-2: Initial Response

What often happens:

• Hot flushes improve quickly (for many women, dramatic reduction within days)
• Night sweats reduce (improved sleep follows)
• Some women report immediate mood lift, energy boost, mental clarity
• OR: Some women feel no change yet (also normal)
• OR: Some women feel worse (also normal — adjustment period)

Potential side effects:

• Breast tenderness begins
• Mild nausea (especially if oral oestrogen)
• Bloating, fluid retention
• Headaches

What you should do:

• Note improvements (even if small)
• Expect side effects to be temporary
• Don’t change anything yet — too early to assess effectiveness

Week 3-4: Adjustment Period

What often happens:

• This is often the roughest phase
• Initial improvements may plateau or reverse temporarily
• Hot flushes might return (milder than pre-treatment but frustrating)
• Mood might feel unstable (ups and downs)
• Side effects may persist or worsen (breast tenderness, bloating)
• Fatigue might worsen temporarily
• Many women consider stopping HRT during this phase

Why this happens:

• Body recalibrating regulatory systems
• Hormone levels stabilizing (process, not instant)
• If perimenopausal, ovarian function still fluctuating

What you should do:

• Persist — this phase is temporary
• Track symptoms (helps you see overall pattern rather than focusing on bad days)
• Manage side effects (supportive bra for breast tenderness, reduce sodium for bloating)
• Don’t increase dose — not a dose problem, an adjustment problem
• Contact prescriber if side effects severe or concerning

Week 6-8: Emerging Stability

What often happens:

• Initial side effects resolve or reduce significantly (breast tenderness, bloating improve)
• Hot flushes more consistently controlled
• Sleep quality improving (if disrupted by night sweats)
• Energy beginning to lift (still variable day to day)
• Mood becoming more stable
• Still fluctuations, but overall trend is improvement

What you should do:

• Continue treatment consistently
• Note overall trend (are good days becoming more frequent? Bad days less severe?)
• Maintain lifestyle interventions (sleep, stress management, exercise, nutrition)

Week 12 (3 Months): Significant Improvement

What often happens:

• Hot flushes well controlled (rare or absent)
• Sleep normalized
• Mood significantly better (anxiety reduced, less irritable, more like yourself)
• Energy improved (though may not be fully back to “normal” yet)
• Cognitive function improving (brain fog lifting, concentration better)
• Side effects mostly resolved
• Still may have occasional “off days” but overall much better

What you should do:

• Assess: Are symptoms adequately controlled?
• If yes: Continue current regimen
• If no: Discuss with prescriber (may need dose adjustment, formulation change, investigation of other factors)

Month 6: Full Effect

What often happens:

• This is when most women reach full benefit
• Symptoms controlled or resolved
• Energy normalized
• Mood stable
• Cognitive function back to baseline
• Feeling “like yourself again”
• May still have occasional minor symptoms (particularly if perimenopausal)
• Life feels manageable again

What you should do:

• Continue treatment
• Annual review with prescriber (minimum)
• Monitor for any changes in symptoms or side effects
• Adjust if needed

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Common Patterns Women Experience

While every woman’s experience is unique, certain patterns are common:

Pattern 1: “The Honeymoon Crash”

Week 1: “This is amazing! All my hot flushes stopped! I feel like a new person!”

Week 3: “Everything’s come back. I feel worse than before. HRT isn’t working.”

Week 8: “Things are settling. Better than before HRT, not as good as week 1, but improving.”

Month 4: “Finally feeling consistently good.”

Why this happens:

• Initial dramatic improvement (hot flushes respond quickly)
• Adjustment period causes temporary relapse
• Body gradually stabilizes
• Eventual consistent improvement

What to do:

• Recognize the pattern
• Don’t stop during week 3 crash
• Give it time

Pattern 2: “The Slow Burn”

Week 1-4: “Nothing’s happening. Is this even working?”

Week 6: “Maybe my hot flushes are slightly less frequent? Hard to tell.”

Week 12: “Looking back, I’m definitely better than 3 months ago. Gradual improvement.”

Month 6: “I feel so much better. Didn’t notice day-to-day changes but the cumulative effect is significant.”

Why this happens:

• Some women don’t have dramatic quick responses
• Improvement is gradual and incremental
• Hard to notice day-to-day but clear over months

What to do:

• Track symptoms systematically (helps you see gradual improvement)
• Be patient
• Don’t expect overnight transformation

Pattern 3: “The Roller Coaster” (Common in Perimenopause)

Ongoing: “Good week, terrible week, okay week, awful week… I can’t predict how I’ll feel.”

Month 3: “Still fluctuating but overall trend is upward — bad weeks less bad, good weeks more frequent.”

Month 6: “Much more stable, though still occasional difficult days.”

Post-menopause (once periods stop completely): “Finally consistent.”

Why this happens:

• Perimenopausal women still producing variable ovarian hormones
• HRT provides baseline but total levels fluctuate
• Stabilizes once fully postmenopausal

What to do:

• Recognize this is perimenopause pattern (not treatment failure)
• Track overall trend (not individual days)
• Consider cyclical vs. continuous combined HRT (discuss with prescriber)
• Will improve once postmenopausal

Pattern 4: “The Steady Climb”

Week 1-2: “Hot flushes reduced. Sleeping better.”

Week 4: “Definitely improving week by week.”

Week 8: “Much better. Still some symptoms but manageable.”

Month 4: “Feeling good. Almost back to normal.”

Why this happens:

• Some women have smooth adjustment (less common but happens)
• Steady, predictable improvement
• Lucky!

What to do:

• Appreciate it
• Continue treatment
• Still monitor for any changes

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What’s Normal vs. What’s Concerning

How do you distinguish between normal adjustment fluctuations and actual problems requiring intervention?

Normal Adjustment (Persist with Treatment):

Fluctuating symptoms:

• Good days and bad days
• Overall trend is improvement (even if non-linear)
• By 6-8 weeks, seeing some benefits even if not complete

Temporary side effects (first 4-8 weeks):

• Mild-moderate breast tenderness (improves over weeks)
• Bloating, fluid retention (improves)
• Mild nausea (improves)
• Headaches (occasional, not severe, improve)

Patience required:

• Most women need 3-6 months for full effect
• Fluctuations during this period are normal

Concerning (Contact Prescriber):

Severe side effects:

• Severe breast pain (not just tenderness)
• Severe, persistent nausea/vomiting
• Severe, unrelenting headaches (particularly if new migraines or migraine with aura)
• Chest pain, leg pain, severe calf pain (potential VTE — seek immediate medical attention)
• Vision changes
• Severe mood changes (suicidal thoughts, severe depression)

No improvement by 3 months:

• Tried HRT for 3+ months, no improvements at all
• May need dose adjustment, formulation change, or investigation of other factors

Worsening symptoms that don’t improve:

• Started HRT, symptoms dramatically worsened and stayed worse (beyond initial 4-8 week adjustment)
• Not just fluctuations, but sustained worsening

New concerning symptoms:

• Vaginal bleeding (if postmenopausal and not on cyclical HRT)
• Unusual discharge, pain, lesions

When in doubt, contact prescriber — better to check than ignore concerning symptoms.

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How to Support Yourself Through the Adjustment Period

Knowing adjustment is normal is helpful — but how do you actually cope with 3-6 months of fluctuations?

1. Set Realistic Expectations

Adjust your expectations:

• HRT is not an instant fix
• Full effect takes 3-6 months (not days or weeks)
• Fluctuations are normal during adjustment
• “Feeling like yourself again” is the goal — not “feeling perfect every single day”

Lower pressure on yourself:

• You’re not failing if you have bad days during treatment
• Treatment not failing if symptoms fluctuate initially
• Recovery is a process, not an event

2. Track Symptoms Systematically

Keep a symptom diary:

• Rate key symptoms daily (hot flushes, sleep, mood, energy, cognitive function) on simple scale (1-10)
• Track menstrual cycle (if still having periods)
• Note any side effects
• Track lifestyle factors (sleep hours, stress levels, exercise, alcohol)

Why tracking helps:

• Reveals patterns you wouldn’t notice otherwise
• Shows overall trend (even when day-to-day feels chaotic)
• Helps distinguish between normal fluctuations and actual problems
• Useful information for prescriber at follow-up

Apps that help:

• Balance (by Dr. Louise Newson — menopause-specific)
• General symptom tracking apps
• Simple paper diary

3. Focus on Overall Trend, Not Individual Days

Perspective shift:

• Don’t judge treatment based on today or even this week
• Look at pattern over weeks and months
• Ask: “Am I better than 6 weeks ago? 3 months ago?”
• Even if still having symptoms, are good days becoming more frequent? Bad days less severe?

This prevents:

• Giving up during temporary difficult phases
• Changing treatment prematurely
• Unnecessary anxiety about normal fluctuations

4. Maintain Lifestyle Foundations

HRT is essential but not sufficient alone — lifestyle factors dramatically affect how you feel during adjustment:

Sleep (non-negotiable):

• 7-9 hours nightly
• Consistent schedule
• Optimize sleep environment
• Sleep deprivation will make every symptom worse, even on HRT

Stress management (daily practice):

• Breathwork, meditation, mindfulness
• Boundaries (saying no to non-essentials)
• Time in nature
• Social connection
• Stress amplifies all menopause symptoms

Movement (essential):

• Strength training 2-3x/week (builds metabolic resilience)
• Daily walking or gentle movement
• Exercise is powerful for mood, energy, sleep

Nutrition (blood sugar stability):

• Protein at every meal (20-30g)
• Limit refined carbs and sugar
• Anti-inflammatory eating pattern
• Blood sugar instability worsens mood, energy, hot flushes

Alcohol (minimize):

• Limit to 1-2 drinks per week maximum (or eliminate)
• Alcohol significantly worsens hot flushes, sleep, mood, anxiety
• Impairs HRT effectiveness

These factors affect your baseline — HRT works on top of your lifestyle foundation. If foundation is poor (terrible sleep, high stress, sedentary, poor nutrition, daily alcohol), HRT effect will be limited.

5. Manage Side Effects Proactively

Breast tenderness:

• Supportive, comfortable bra (even to sleep initially)
• Avoid caffeine (can worsen)
• Usually improves within 4-8 weeks

Bloating:

• Reduce sodium intake
• Stay hydrated
• Gentle movement
• Usually improves within 4-8 weeks

Nausea (if oral oestrogen):

• Take with food
• Take at bedtime
• Consider switching to transdermal (patches/gel) if persistent

Headaches:

• Ensure adequate hydration
• Manage stress
• Regular sleep schedule
• If severe or persistent, contact prescriber (may need to switch formulation)

6. Connect with Others

Menopause can feel isolating — connecting with women going through similar experiences helps:

Online communities:

• Menopause Support UK (Facebook)
• Reddit r/Menopause
• Other menopause forums

Benefits:

• Validation (“I’m not alone, others experience this too”)
• Practical tips from women ahead of you in the process
• Emotional support
• Reduces sense of isolation

Caution:

• Remember everyone’s experience is different
• Don’t compare your timeline to others
• Verify medical advice with healthcare professional

7. Communicate with Prescriber

Keep your prescriber informed:

• Scheduled follow-up (typically 6-12 weeks after starting)
• Contact sooner if severe side effects or concerns

At follow-up, report:

• Which symptoms have improved
• Which persist
• Side effects experienced
• Overall assessment: “Better, same, or worse than before starting?”

This helps prescriber:

• Assess if current regimen appropriate
• Decide if adjustments needed
• Provide reassurance about normal adjustment patterns

8. Be Patient with Yourself

This is hard.

• You’ve been suffering with menopause symptoms for months or years
• You started treatment hoping for quick relief
• Adjustment period is frustrating and disappointing
• Be kind to yourself

Self-compassion:

• You’re not weak for struggling
• You’re not failing if you have bad days
• Your body is going through significant hormonal recalibration
• It’s okay to feel frustrated
• It’s okay to need support

Recovery takes time — but it does happen for most women.

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When to Adjust Treatment

At what point should you discuss changing HRT regimen rather than just waiting through adjustment?

Consider Adjustment If:

Severe, intolerable side effects:

• Severe breast pain, nausea, headaches that aren’t resolving after 4-8 weeks
• May need different formulation or dose

No improvement at all by 3 months:

• Tried HRT for 3+ months
• No benefits whatsoever
• May need higher dose, different type, or investigation of other factors

Partial improvement but key symptoms persist:

• Some symptoms better (hot flushes controlled) but others not (mood, energy still poor)
• May need dose adjustment, addition of testosterone, or addressing other factors

Symptoms initially improved then worsened:

• First few weeks were great, then symptoms returned and stayed
• May indicate dose too low or other issue

Formulation clearly not working for you:

• Patches constantly falling off
• Gel impractical for your lifestyle
• Oral causing persistent nausea
• Can switch formulations

Typical Adjustments:

Dose change:

• Increase oestrogen dose (e.g., 50 mcg patch → 75 or 100 mcg)
• Adjust progesterone dose or type

Formulation change:

• Oral → transdermal (or vice versa)
• Patch → gel (or vice versa)
• Cyclical → continuous combined (or vice versa)
• Synthetic progestogen → micronized progesterone

Addition of testosterone:

• Particularly if surgical menopause or persistent fatigue/low libido despite adequate oestrogen

Investigation of other factors:

• Thyroid function
• B12, iron, vitamin D
• Other health issues

Work with your prescriber — don’t adjust on your own.

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The Bottom Line

Menopause recovery is NOT linear.

The expectation of “start HRT → feel better immediately and steadily” is unrealistic and sets women up for frustration and premature discontinuation of treatment.

The reality:

• Initial response varies (dramatic improvement, no change, or temporary worsening)
• Weeks 3-4 often roughest (adjustment period)
• Different symptoms improve at different rates
• Fluctuations are normal, especially in perimenopause
• Full effect takes 3-6 months
• Even after stabilizing, you may have occasional “off days”

This non-linear pattern is NORMAL — not a sign of treatment failure.

What you should do:

• Set realistic expectations (3-6 months for full effect)
• Track symptoms systematically (reveals overall trend)
• Focus on overall pattern, not individual days
• Maintain lifestyle foundations (sleep, stress management, exercise, nutrition, limit alcohol)
• Manage side effects proactively
• Be patient with yourself
• Communicate with prescriber
• Don’t give up during adjustment period — most women who persist see significant improvement by 3-6 months

When to contact prescriber:

• Severe side effects
• No improvement at all by 3 months
• Concerning symptoms
• Questions or concerns

Recovery takes time — but it does happen.

The challenging adjustment period is temporary. The benefits of well-managed menopause can last years or decades.

Be patient. Be kind to yourself. Keep going.

You will feel like yourself again.

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Need Support?

If you’re struggling with the adjustment period on HRT or finding it difficult to persist through the fluctuations, I can help.

As a registered nurse and prescriber specializing in menopause care, I provide ongoing support throughout your menopause journey, including managing the adjustment period and optimizing your regimen.

Book a consultation for personalised guidance and support.